Best Approaches

The effectiveness of various treatment and prevention interventions was the theme of the final day’s first session.

Acute HIV infection was the subject of Dr. Christina Polyak’s presentation. She described findings from the Early Capture HIV Cohort (ECHO) and the challenges with identifying cases of acute infection. Dr. Polyak suggested difficulties in evaluating the impact of various interventions might be addressed by developing special cohort studies.

Dr. Réka Gustafson, Medical Health Officer at Vancouver Coastal Health, described the benefits of engaging the medical community in order to expand routine HIV testing. Opportunities for diagnosis were being missed, she said. By presenting compelling data, describing the importance of screening, and providing follow-up support, a 90% increase in HIV testing in Vancouver was achieved.

Increasing testing, linkage-to-care, and retention in care is critical to the U.S. strategy, said Dr. Carlos del Rio of the Emory University School of Medicine. Retention, he said, is critical as a predictor of virologic suppression. However, there is no effective way to measure retention nor to predict who will be at risk of poor retention. There is still a need, Dr. del Rio said, for better studies to know what works.

Dr. Jean Nachego from the Johns Hopkins Bloomberg School of Public Health presented challenges with treatment adherence. He described effective interventions as weekly SMS text messaging and treatment supporters.

Serodiscordant couples have been the focus of Treatment as Prevention intervention efforts in Vietnam. Dr. Thi Thuy Van Nguyen said early research outcomes have shown couples HIV testing and counselling, as well as immediate provision of ART, have been effective at identifying serodiscordant couples, improving retention, achieving viral suppression.

Dr. Sam Phiri, Director of the Lighthouse Trust, described the lessons from implementing Option B+ for preventing mother-to-child-transmission. The approach calls for immediate ART initiation for pregnant women and breastfeeding mothers. They found 94% treatment adherence among women retained into to care, with similar results in virologic suppression and vertical transmission rates. However, the best approach remains unclear, as immediate treatment also led to lower retention rates while deferred treatment initiation led to higher retention.

Lessons from San Francisco were presented by Dr. Susan Buchbinder. The profile of the epidemic is unique in the city, she said, as HIV is concentrated among males, particularly men who have sex with men and men who inject drugs. Data suggest that in order to drive new HIV infections down to zero, PrEP and prevention should be implemented in combination with treatment.

Gus Cairns of aidsmap advocated for community consensus on the use of antiretroviral therapy in preventing HIV transmission. The history of HIV, he said, is defined by tension between the concern about the enforcement of treatment and concern about withholding it. A community consensus statement was launch earlier this year by aidsmap and European AIDS Treatment Group (EATG). The consensus statement is accessible at www.hivt4p.org.

Underestimated Benefits

The World Bank’s Dr. David Wilson was the final presenter at this workshop. The director of the Global HIV/AIDS Program discussed the benefits of health on wealth, both at the individual and national level. Evidence has shown good health has a positive effect on education, productivity, investment, and ratio of workers to dependents. If we can eliminate AIDS for costs comparable to existing plus proportionate scale-up costs, he argued, the macroeconomic impact on GDP would be profound.

Dr. Wilson’s presentation was part of the final session’s theme of the underestimated benefits of Treatment as Prevention. His macroeconomic discussion was preceded by a presentation on the microeconomic benefits. Dr. Harsha Thirumurthy from the University of North Carolina described how health improvements influence various individual and household socio-economic outcomes. Many analyses of ART provision undervalue its impact by focusing on costs and health impacts. Further benefits may lie in preventing economic decline rather, improving children’s schooling outcomes and averting end-of-life expenses.

Drs. Nina Kim and John Ward presented on the benefits of Treatment as Prevention on Hepatitis B and Hepatitis C, respectively. Dr. Kim, an Associate Professor of Medicine at the University of Washington, spoke about the prevalence of chronic HBV in the HIV-infected population, and the increased health burdens caused by coinfection. She described how ART can be expected to benefit these patients, as well as upcoming challenges, particularly in resource-limited settings.

Dr. John Ward from the U.S. Center for Disease Control presented on HCV Treatment as Prevention strategies. One opportunity for implementation, he said, is expanding testing in correctional facilities, where there are approximately 375,000 HCV-infected persons who contribute to transmission during and after incarceration. He called for further capacity-building to improve continuum of HCV testing, care, and treatment.

Dr. Haileyesus Getahun from the World Health Organization’s Global Tuberculosis Programme presented on Treatment as Prevention for TB. He pointed to studies demonstrating that ART expansion has led to a decrease in TB incidence. However, Treatment as Prevention for TB cannot be scaled-up in isolation or before addressing concerns of country programs, he said.

The clinical benefits of Treatment as Prevention were presented by Dr. Celso Ramos Filho from Brazil’s National Academy of Medicine. He presented research demonstrating the clinical benefits of early ART initiation. The key, he said, is not to start treatement too early, but to start it soon enough.

Dr. Howard Strickler from the Albert Einstein College of Medicine presented on HPV. Research has shown treatment appears to interrupt progression to cancer. He cautioned clinicians that should avoid raising expectations of cure and instead focus on the achievable goal of cancer prevention.